The treatment of intrahepatic bile duct stones is a clinical challenge in surgery. Due to various reasons of awareness, anatomy, pathology and technology, there are still many problems in the treatment of intrahepatic bile duct stones, which affect the therapeutic effect. Therefore, we should pay special attention to it and treat it seriously.
1. Difficulties in the surgical treatment of intrahepatic bile duct stones. Because the pathology of hepatobiliary duct stones is very complex, it is another disease that is different from gallbladder stones in terms of ideological understanding, and cannot be treated according to the principles and methods of treating gallbladder stones. Gallbladder stones can be treated by oral or puncture lithotripsy, and have achieved certain effect, but there is no ideal lithotriptic drug for intrahepatic bile duct stones; gallbladder stones can be completely treated by removing the gallbladder, but intrahepatic bile duct stones cannot be extensively removed from the bile ducts. This is technically difficult to be treated completely in one operation. Sometimes the patient is in critical condition such as acute cholangitis, shock, etc., and emergency surgery is performed, and the preoperative condition is unclear or only emergency measures are allowed, leaving intrahepatic lesions behind. The combination of liver cirrhosis and portal hypertension with hepatic bile duct stones makes surgical treatment of hepatic bile duct stones very difficult, resulting in frequent postoperative residual stones and bile duct strictures. Domestic statistics show that the incidence of postoperative residual stones in hepatobiliary stones is as high as 40% to 70%, and the proportion of residual intrahepatic bile duct stenosis is even higher, so that about 30% of cases require another biliary surgery. Seriously, in many patients, as the number of operations increases, the pathology becomes more complex and bile duct strictures are more likely to occur, requiring reoperation again. This increases surgical complications and mortality.
2, the principles of surgical treatment of intrahepatic bile duct stones. With the improvement of medical practice and the advancement of treatment technology, the systematic approach has improved the understanding that the treatment of hepatobiliary stones must adhere to the principles of holistic, comprehensive and dialectical. The concept of imaging and stereoscopic imaging of the hepatic portal anatomy has made it possible to convert traditional extrahepatic surgery to intrahepatic surgery. For the treatment of intrahepatic bile duct stones, hepatic surgery techniques are used to deal with the porta hepatis and intrahepatic bold ducts to achieve good exposure, forming a more complete principle of surgical treatment of hepatic bile duct stones, i.e., removing the stones, removing the lesions, correcting the bile duct strictures, restoring and establishing the physiological function of the biliary tract and unobstructed bile flow, avoiding and preventing biliary tract infection and recurrence of stones.
3. Make good preoperative preparation and avoid acute surgery Systematic planning and overall design according to treatment principles. For patients with intrahepatic bile duct stones, try not to perform surgery in acute cases, especially when the pathology is not very clear. A combination of Chinese and Western medicine can be used to give appropriate antibiotics, bile duct decompression via a nasal bile duct, or percutaneous hepatic puncture for bile duct drainage to correct water-electrolyte disorders and acid-base balance to survive the emergency period. Preoperatively, we actively treat various complications, diagnose clearly the site of gallstone, the site and degree of bile duct stricture, the pathological condition of biliary tract inside and outside the liver, liver function and general condition. According to the lesion and the actual possibility, the treatment plan should be formulated and the first operation should be done well. In cases where multiple surgeries have been performed, careful consideration and careful design should be made to strive for the last surgery.
4. Combination surgery and follow-up treatment
(1) Combination surgery: The requirements of surgical treatment of hepatobiliary stones are difficult to be completely solved in one operation with a certain surgical modality, and multiple surgical modalities must be combined to complement each other to meet the treatment needs. For example, if the stone is located in the left lobe or the left lobe has hepatic fibrosis or hepatic tissue atrophy, the left lobe of the liver or the left outer lobe of the liver can be resected, and if it is combined with hilar bile duct stenosis, hilar choledochoplasty can be performed. The function of the sphincter is preserved as much as possible. In case of extensive stones in the left and right lobes of the liver and combined with hilar bile duct stenosis, the hepatic duct can be incised from the hepatic duct to reveal the intrahepatic 1 to 2 levels of hepatic duct upward to release the stenosis and remove the intrahepatic stones. And it is suctioned while lithotripsy, and all stones can be removed intraoperatively in most cases, which, together with postoperative choledochoscopic treatment, improves the treatment effect of intrahepatic bile duct stones.
If the extrahepatic biliary stricture is no longer available, or if the patient is a reoperative patient, after treatment of intrahepatic stones and release of biliary stricture, a hilar biliary or intrahepatic biliary jejunojejunal Roux-Y anastomosis is appropriate. The important point is that if the residual lesions in the liver, especially intrahepatic bile duct strictures are not released and bile-intestinal anastomosis is performed below the strictures, then not only the bile flow is not solved after surgery, but also the intestinal bile reflux will be increased and biliary infection or severe cholangitis will occur or the stones will recur, which is a common clinical reason for reoperation.
(2) Follow-up treatment: That is, intrahepatic or extrahepatic intra-biliary catheter is placed during surgery, and this catheter can be a simple catheter or a balloon catheter. The location of the catheter placement depends on the presence or absence of residual stones inside or outside the liver, the presence or absence of biliary strictures and the function of the catheter. Some intra- and extrahepatic bile duct strictures or intra-anastomotic support catheters, and balloon catheters, need to be retained for a longer period of time, usually 6 to 12 months. For patients requiring long-term placement, a U-shaped tube may be used to reduce bile loss.
Postoperative endobiliary ducts can serve multiple purposes.
① Perform drainage of infected bile;
②Supporting the bile-intestinal anastomosis;
(iii) support and dilate biliary strictures;
④Drip medication through the catheter for anti-inflammation, hemostasis, and lithotripsy;
⑤ Lithotripsy by acoustic frequency hydraulic shock through the catheter;
⑥Treatment by choledochoscopy through the sinus of the catheter to remove residual stones or lithotripsy;
(vii) Cholangiography through the catheter to observe the pathology of the intra- and extra-hepatic bile ducts and to decide the next treatment and whether to remove the catheter. These measures are the continuation and supplement of surgical treatment, and only the combination of surgery and follow-up treatment well combined can improve the effect of surgical treatment of intrahepatic bile duct stones.
5.The treatment of several difficult problems of hepatobiliary duct stones
(1) Hepatobiliary stones complicating cirrhotic portal hypertension: pathological changes in the liver of hepatobiliary stones, mainly in the liver tissue around the bile ducts and the confluent area, with the development of chronic inflammation, liver tissue fibrosis, narrowing of the portal lumen and thickening of the duct wall. The hepatic artery within the confluence area is significantly dilated, the inner diameter is thickened, the portal blood flow is compressed, the blood return is reduced, and the liver tissue is atrophied, which is the cause of portal hypertension. Combined with repeated episodes of cholangitis and peri-cholangitis, bile stagnation, hepatocyte damage and regeneration, the formation of biliary cirrhosis, with the aggravation of the disease portal hypertension is also more developed. Therefore, portal hypertension in patients with hepatobiliary stones is secondary to long-term bile duct obstruction and severe jaundice as a result of cirrhosis. In such patients, in addition to the usual portal interbody collateral circulation, there is a large number of venous networks and varices in the region of the extrahepatic bile ducts of the hepatic portal. The greatest difficulty in surgery is the uncontrollable hemorrhage during surgery, which is the main cause of failure. It is even more difficult if for re-operation.
Treatment principles: The first step for this complicated case is to strengthen the pre-surgical preparation, control the infection and improve the liver function, and then operate in stages. The first step is to first splenectomy plus intestinal lumen shunt to reduce portal vein pressure and prepare for reducing surgical bleeding. The second step is to perform complete surgery for hepatobiliary stones 3 to 6 months after surgery, depending on the situation.
(2) Reoperation for multiple surgeries of hepatobiliary stones: Due to its pathological complexity, the residual rate of gallstones and recurrence rate after surgery is high for hepatobiliary stones, or repeated attacks of recurrent septic cholangitis due to improper previous surgical methods, resulting in multiple surgeries and further complicating the pathological situation. When reoperation is required, it undoubtedly increases the difficulty of surgery.
In addition to the problems associated with biliary reoperation, the main points of attention are as follows.
① Pre-operative strengthening of the general condition, comprehensive analysis of the patient’s reasons for reoperation, with emphasis on resolving residual stones, bile duct strictures, establishing or repairing unobstructed biliary flow, correcting defects of previous surgery, improving or setting up anti-biliary intestinal reflux measures, and reducing postoperative biliary tract infection and stone recurrence.
②Select the appropriate surgical access through the liver pericardium to anatomically reveal the deep bile ducts of the transverse hepatic fissure, sometimes encountering uncontrollable bleeding. For thickened liver pericardium adhesions and increased vascular plexus, try to separate from outside the liver pericardium, stop bleeding with electrocoagulation, carefully identify the tissue, do not blindly clamp, and stop bleeding with sutures if needed. At the same time, we should take into account the liver transposition and displacement of hepatoportal structures in patients with hepatobiliary stones, and we can separate while puncturing to find the extrahepatic bile ducts.
(3) Intraoperative with ultrasound, intraoperative imaging, when the hepatic hilar is really difficult to dissect, the bile duct can be removed or drained through the liver parenchyma by incision.
(3) Treatment of residual intrahepatic bile duct stones: It is a difficult problem in surgical treatment that there are still residual stones after hepatic bile duct stone surgery. Although with the continuous improvement of surgical techniques, the incidence of residual stones after intrahepatic bile duct stone surgery is still high. According to Huang et al, the incidence of residual stones was 30.36% in 4197 cases of intrahepatic bile duct stones after surgery in 19 provinces and cities in China, and there were reports of residual stone rate up to 90% after surgery.
Treatment principles.
① Actively treat complications caused by residual stones, such as biliary tract infection, liver abscess, obstructive jaundice, etc.
② For those with biliary ducts after surgery, lithotripsy and lithotripsy with choledochoscope can be performed 4-6 weeks after surgery via ductal sinus tract. The method: A. If there is bile duct stricture, choledochoscopy or balloon catheter dilation is first performed via sinus tract. It can also be combined with duodenoscopy to perform papillary sphincterotomy to resolve the stenosis of the lower end of the common bile duct; B. Choledochoscopy for stone extraction, choledochoscopy through the ductal sinus tract should be performed carefully and gently, according to the preoperative diagnosis and the situation in the bile duct, such as bile duct inflammation, flocculent material, determination of the site of the residual stone, or under ultrasound guidance, into the intrahepatic bile duct. For large stones, they can be chewed up with lithotripters and then clamped out. After the intrahepatic bile duct is removed, the extrahepatic bile duct is then examined up to the opening of the lower end of the common bile duct. If the stone cannot be removed at one time, it can be removed several times. The interval between each extraction is 3-5 days. In case of postoperative cholangitis, the stone should be retrieved after the inflammation is controlled. After each stone extraction, the catheter should be put back into the bile duct to facilitate drainage on the one hand, and to create conditions for later stone extraction again. For intrahepatic bile ducts of grade 4 or above, if the choledochoscope cannot enter, the stone can be removed by acoustic frequency hydraulic vibration lithotripsy to loosen the stone from the terminal bile duct to the bold duct. Alternatively, a fine choledochoscope can be used to go to the opening of the bile duct and a stone extraction forceps can be used to enter the distal bile duct to retrieve stones.
Difficult to handle residual stones because the diameter of the T-shaped duct or intrahepatic duct is too thin, or the sinusoidal tract of the duct is too coiled and tortuous for the choledochoscope to enter. In this case, the duct should be introduced with a guidewire first and replaced with a thicker duct at an interval of 3 to 5 days for gradual expansion or guided by the guidewire into the choledochoscope for stone extraction. Next is the stenosis of the biliary branch of the residual stone, which is mostly relative stenosis or membranous stenosis and can be passed by direct expansion with the choledochoscope. If the stenosis is severe and the choledochoscope is difficult to dilate, a guide wire should be used to guide the dilatation tube to dilate the stone first and then use the choledochoscope to retrieve it later. Furthermore, because the residual stone is located in the posterior or caudal branch of the right lobe of the liver, the opening of the bile duct is at an angle, making it difficult to find or access the biliary tractoscope. In this case, we should refer to ultrasound, CT, ERCP and other imaging examinations before surgery to study the location of the residual stone, and enter the choledochoscope from the sinusoidal tract under the guidance of ultrasound to find the bile duct opening, and if the opening angle is too small, we can make the choledochoscope bend sideways to enter to retrieve the stone.
(iii) Treatment of residual stones in those who no longer have biliary ducts after surgery is more difficult. Therefore, before removing the biliary drainage tube after surgery, cholangiography or cholangioscopy is routinely performed to confirm that there are no residual stones or bile duct strictures before the patient is removed. If a residual stone is found when there is no longer a biliary drainage tube.
Prognosis
The reconceptualization of the clinicopathological changes in intrahepatic bile duct stones has updated the traditional concept of treatment. Mechanical obstruction of stones, biliary tract infection, and corresponding pathological changes in the liver parenchyma are the basic pattern of the development of intrahepatic bile duct stones. When Huang Zhiqiang chaired the Biliary Surgery Group of the Chinese Society of Surgery, a survey of 4197 cases of intrahepatic bile duct stone surgery nationwide showed that 39.4% (1654/4197) had various serious complications at the time of treatment, and thus were more advanced cases, mostly accompanied by extensive hepatic The rate of residual stones, reoperation and recurrence are all high after surgery. The current improvement in diagnostic imaging technology and the widespread use of antibiotics facilitate the early detection and timely treatment of intrahepatic bile duct stones. Most of the intrahepatic bile duct stones in this group of patients are confined to one or two liver segments, which can still cause extensive liver damage if they are not treated early and timely. Therefore, it is proposed that the understanding of the clinicopathological changes of intrahepatic bile duct stones should be shifted from the past understanding of advanced diffuse liver damage to the understanding of early local stage changes, so that the traditional concept of relieving symptoms by simply targeting the complications of advanced stones can be changed to the new concept of “radical” removal of lesions to achieve the purpose of cure. The most common locations of early intrahepatic bile duct stones are in the right posterior hepatic segment and the left upper external bile duct. “We have achieved more satisfactory treatment results.